<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366423587
Report Date: 12/14/2022
Date Signed: 12/14/2022 03:31:53 PM


Document Has Been Signed on 12/14/2022 03:31 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507



FACILITY NAME:SARAH JANE GUEST HOMEFACILITY NUMBER:
366423587
ADMINISTRATOR:MOLANO, NINAFACILITY TYPE:
740
ADDRESS:25488 NICKS AVENUETELEPHONE:
(909) 799-7501
CITY:LOMA LINDASTATE: CAZIP CODE:
92354
CAPACITY:6CENSUS: 2DATE:
12/14/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Nina Molano Administrator TIME COMPLETED:
03:35 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
The is an amended document originally delivered on 9/27/2022

On 9/27/2022 Licensing Program Analyst (LPA) Bernadette Allen was at the facility to initiate a complaint investigation CONTROL NUMBER 56-AS-20220629105809

An exit interview was conducted where this report was discussed and provided to xxxxx at the conclusion of the visit

SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette AllenTELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1